The Clinical Assessment and Treatment of Inhalant Abuse.

Although inhalant abuse is common, it is one of the most neglected and overlooked forms of substance abuse. Inhalants refer to a wide variety of substances including volatile solvents, aerosols, gases, and nitrites. The mechanism of action of inhalants has not been fully defined. Several molecular targets contribute to the pharmacology, including ion-channel proteins that control neuronal excitability. These agents interact with various receptors and can cause changes in cell-membrane fluidity and nerve-membrane ion channels. Three main pharmacologic categories of inhalants, namely, volatile solvents and anesthetic gases, nitrous oxide, and volatile alkyl nitrites, have distinct pharmacologies, mechanisms of action, and toxicities. Inhalants are linked to multisystem damage affecting the pulmonary, cardiac, dermatologic, renal, hematologic, gastrointestinal, hepatic, and neurologic systems. Chronic inhalant abuse can also cause psychiatric, cognitive, behavioral, and anatomical deficits in humans, leading to reduced productivity and quality of life. Inhalant abuse during pregnancy is associated with fetal abnormalities. Clinical assessment for inhalant abuse should be done systematically. After decontamination and stabilization of the patient, further history and physical examination is necessary to establish an appropriate diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Laboratory testing for inhalant abuse is very limited, and imaging studies may be helpful in certain situations. The treatment of inhalant use disorder is similar to that of other substance abuse disorders and includes supportive care, pharmacotherapy, and behavioral therapy. Preventive measures are essential.

Adrenoleukodystrophy presenting as glue sniffing.

Adrenoleukodystrophy classically presents in childhood with bronze skin, spastic tetraparesis, dysphagia, behavioural abnormalities and adrenal insufficiency. However, atypical presentations are known. Here we report an adolescent with adrenoleukodystrophy who first sought medical attention for glue sniffing.

Perfil clínico y conductual de jóvenes usuarios de inhalables / Clinical and behavioral profile of young inhalant users

Introducción. En la actualidad el uso indebido de inhalables está aumentando: el potencial adictivo se ha demostrado en diversos estudios. Hasta ahora no había evidencia clínica cuantificable de las características conductuales de los usuarios de inhalables. El objetivo principal fue evaluar el craving, la impulsividad, los comportamientos frontalizados y el reconocimiento de emociones en jóvenes usuarios de inhalables. Método. Fueron evaluados once varones, edades entre 15-22 años (17,3 ± 2,14), escolaridad entre 3-12 años (8,18 ± 2,56). Resultados. La evaluación evidenció que los usuarios de inhalables exhiben indicios de craving, rangos elevados de impulsividad, déficits comportamentales del sistema frontal y dificultades para la detección de expresiones emocionales. Conclusión. En la adicción a inhalables se exhiben síntomas de craving y alteraciones comportamentales, el tiempo de uso incrementa los comportamientos frontales

Introduction. Currently, misuse inhalants is increasing: addictive potential has been demonstrated in several studies. Until now there was no quantifiable clinical evidence of behavioral characteristics inhalant users. Main objective was to evaluate craving, impulsivity, frontalized behaviors and recognition of emotions in young inhalant users. Method. Eleven male, aged 15-22 years (17.73±2.14), schooling 3-12 years (8.18 ± 2.56) were evaluated. Results. Evaluation showed that inhalant users exhibit signs of craving, high ranges of impulsivity, frontal behavioral deficits and difficulties detection of emotional expressions. Conclusions. In inhalants addiction, symptoms of craving and behavioral alterations are exhibited, time use increases frontal behaviors

Multi-Organ System Injury from Inhalant Abuse.

We present an illustrative case of a 24-year old male who developed cardiovascular and multi-organ system toxicity after inhaling a keyboard dust cleaner containing a halogenated hydrocarbon. In the field, the patient demonstrated neurotoxic effects in addition to electrocardiographic changes concerning for toxic myocarditis. We discuss the types of hydrocarbons, methods of abuse, and toxic effects of their inhalation including "sudden sniffing death" from myocardial sensitization.

Volatile substance related deaths: a simple and safe autopsy procedure for sampling and preserving aliphatic hydrocarbons.

Volatile substance abuse in order to "get high" is a widespread problem especially among adolescents and young-adults, with significant rates of morbidity and mortality. Despite the studies conducted on this topic, collection and preservation of volatile substances in forensic context is still a matter of debate: there are several scientific papers describing materials and procedures for volatile substance sampling while performing post mortem examinations and how they influence the development of the forensic case. Most of the proposed techniques involve the use of specific, and sometimes expensive, gas tight materials that are not always available. The aim of this paper is to share a simple method for rapid and effective volatile substance sampling that can be used in both evident and suspected VSA-related deaths. The strength of this procedure is to be applicable even in cases when specific gas tight instruments for sampling, collection and preservation of volatile substances are not available.

Air due to Glue: Spontaneous Pneumothorax in a Young Adult with Glue Sniffing.

Solvent abuse, as inhalant specially, in the form of low cost adhesives like dendrite is common in low income countries among children and the teens. This habit is often a stepping stone to harder drugs. The neurological and neuropsychological effects of solvent abuse are well explored. But the respiratory effects are often overlooked. In this report, we present a case of a 19 year old gentleman, with regular history of sniffing of commercial "glue" compounds. This patient presented with right sided chest pain and chest x-ray showed a right sided pneumothorax. The pulmonary barotrauma, possibly due to increased intra-alveolar pressure, during the sniffing process can lead to alveolar rupture and in turn, pneumothorax. In the absence of other risk factors for Pneumothorax, the link between inhalant abuse and respiratory complications has to be explored in patients with history of such abuse. Keywords: inhalant abuse; pneumothorax; solvent.

Neuropsychiatric characterization of individuals with inhalant use disorder and polysubstance use according to latent profiles of executive functioning.

BACKGROUND: Inhalant use disorder (IUD) is associated with deficits in executive functions (EFs). We described latent profiles of EFs and distribution of neuropsychiatric disorders and patterns of severity of use across these profiles. METHODS: Individuals with IUD were recruited at community-based residential facilities for substance use treatment in Mexico City. Latent profile analysis was conducted with the following tasks: self-ordered pointing, Stroop, Iowa gambling, Wisconsin Card Sorting and Tower of Hanoi. RESULTS: Three latent profiles were extracted from n = 165: lowest performances of inhibition of response and processing speed; lowest performance of self-monitoring, intermediate performance of inhibition of response and relatively spared processing speed; and intermediate performance of processing speed and self-monitoring, and relatively spared inhibition of response. CONCLUSION: Between-group differences were observed mainly for antisocial personality disorder and lifetime suicidal. Findings remark the need for identifying distinct profiles of EFs within these populations to better understand the transdiagnostic heterogeneity of EFs.

Acute harms associated with inhalant misuse: Co-morbidities and trends relative to age and gender among ambulance attendees.

BACKGROUND: Inhalant misuse is the deliberate inhalation of products containing toluene to induce intoxication. Chronic harms associated with inhalant misuse are well described; including alcohol and other drug use, mental health disorders, and suicidal behaviours. However, the nature of the acute harms from inhalants and characteristics of people who experience those harms are not well understood. Therefore, this study aimed to identify the acute harms associated with inhalant misuse attendances, and to determine whether these differ by age or gender. METHODS: Ambulance attendance data (Victoria, Australia) from January 2012 to June 2017 were extracted from a database of coded ambulance records. 779 ambulance attendances involving inhalant misuse were identified. Attendance characteristics were categorised by age and gender. Co-morbidities of current mental health, self-harm and suicidal behaviour were assessed, plus the involvement of alcohol and other drugs. RESULTS: Overall, attendances related to the acute harms of inhalant misuse have decreased over time, although that trend has reversed from January 2015. Gender differentiated the acute harms associated with inhalant misuse. Males were older and presented with concurrent alcohol and other drug use. Females were younger and presented with concurrent suicidal ideation and self-injury. Attendances for under 15-year-olds are increasing; this age group was over-represented, predominantly female, with a strong association with self-injury. CONCLUSIONS: Ambulance presentations related to inhalant misuse were associated with acute and serious harms. This study highlights that the acute treatment needs of those misusing inhalants are complex and may need to be tailored to gender and age groups.

A novel approach of substitution therapy with inhalation of essential oil for the reduction of inhalant craving: A double-blinded randomized controlled trial.

Inhalants, which are neurotoxic central nervous system (CNS) suppressants, are frequently abused by young adults. Unlike other CNS depressants, including alcohol and opiates, no treatment is currently approved for inhalant dependence. In this report, a novel approach of substitution treatment for inhalant addiction was explored in a double-blinded, randomized, controlled crossover design to examine the effects of inhalation of essential oil and perfume on the reduction of cue-induced craving for inhalant in thirty-four Thai males with inhalant dependence. The craving response was measured by the modified version of Penn Alcohol Craving Score for Inhalants (PACS-inhalants). The participants (mean age ± SE = 27.9 ± 1.4) in this trial had used inhalant for 5.8 ± 1.1 years. Cravings could be induced in all participants by visual cues as assessed by ^50% increases in inhalant craving levels. Generalized estimating equations showed a significant suppressant effect of essential oil, but not perfume, on the craving response as compared with baseline cue-induced craving. Moreover, essential oil, but not perfume, had significant effects on physiological responses including decreasing pulse rate. It is concluded that inhaling essential oil as a substitution treatment for inhalant may be used as part of treatment programs for reducing inhalant craving.

Substance Use Disorders in Adolescence Exist along Continua: Taxometric Evidence in an Epidemiological Sample.

A longstanding nosological question in the clinical literature is whether substance use disorders (SUDs) are best conceptualized as categorical or dimensional phenomena. Taxometric analysis is a statistical approach uniquely developed to address this issue. To date, no taxometric studies have been conducted with SUDs in adolescents. The current taxometric study investigated the latent structure of SUDs in adolescents for four different substances: marijuana, analgesics, hallucinogens, and inhalants. Interview-derived data for DSM-IV SUD symptoms were drawn from the National Survey on Drug Use and Health, pooled across the years 2004 to 2013 (unweighted n = 181,573; 48.92% female). Two mathematically non-redundant taxometric methods (MAMBAC [mean above minus below a cut] and MAXEIG [maximum eigenvalue]) were conducted with the data for respondents who had used the substance under study at least once in the past 12 months, or on 5 separate days in the case of marijuana (unweighted ns = 4900 to 17,517). Consistent evidence emerged in support of a dimensional solution across the analyses for all four substances (mean comparison curve fit index = 0.129 to 0.301). The current findings are consistent with the view of SUDs in adolescents as continuous syndromes rather than discrete entities. These findings are also consistent with theoretical conceptualizations of SUDs as having multi-causal etiologies, and have implications for current diagnostic conceptualizations of SUDs.

Adolescent inhalant use prevention, assessment, and treatment: A literature synthesis.

Inhalant use refers to the use of substances such as gases, glues, and aerosols in order to achieve intoxication, while inhalant use disorder (IUD) encompasses both DSM-IV-TR criteria for inhalant abuse and dependence. Inhalant use among adolescents is an international public health concern considering the severe medical and cognitive consequences and biopsychosocial correlates. In this paper, we summarize the current state of the literature on inhalant use among adolescents focusing on social context, prevention, assessment, and treatment strategies. Psychoeducation, skills training, and environmental supply reduction are helpful strategies for preventing adolescent inhalant use, while parent and adolescent self-report as well as physician report of medical signs and symptoms can aid in assessment and diagnosis. Although research has only begun to explore the treatment of inhalant use, preliminary findings suggest that a multimodal approach involving individual counselling (i.e., CBT brief intervention), family therapy, and activity and engagement programs is the first-line treatment, with residential treatment programs indicated for more severe presentations. The limited nature of treatments developed specifically for inhalant use combined with high prevalence rates and potential for significant impairment within the adolescent population indicate the need for further research. Research should focus on understanding the social context of use, establishing the efficacy of current adolescent substance use treatments adapted for inhalant use, and exploring long-term outcomes.

Acute myocardial infarction, associated with the use of a synthetic adamantyl-cannabinoid: a case report.

BACKGROUND: "Legal highs" are novel psychoactive substances that have evaded statutory control. Synthetic cannabinoid compounds with adamantane moieties have recently been identified, which have high potency at target receptors and are undetectable on conventional toxicology testing. However, little is known about any harmful effects, and their potential to cause serious ill health. We describe a case of myocardial infarction following the use of this class of drug. CASE PRESENTATION: We report the case of a 39-year-old man admitted after an out-of-hospital cardiac arrest, in whom ECG and elevated cardiac enzymes confirmed ST-elevation myocardial infarction. Normal coronary perfusion was restored after thrombectomy and coronary artery stenting. In the hours preceding his admission, the patient is known to have consumed the legal high product "Black Mamba". Subsequent urine testing confirmed the presence of an adamantyl-group synthetic cannabinoid, whilst cannabis, cocaine, amphetamines and other drugs of abuse were not detected. CONCLUSION: The use of legal highs is being increasingly recognised, but the chemical compositions and physiological effects of these drugs are poorly characterised and are continually changing. Synthetic cannabinoids, rarely identified on toxicological testing, can be linked to serious adverse cardiovascular events. This case highlights the importance of testing for novel psychoactive compounds, and recognising their potential to cause life-threatening conditions.

Medico legal investigations into sudden sniffing deaths linked with trichloroethylene.

Sudden deaths attributed to sniffing trichloroethylene are caused by the abuse of this solvent which produces pleasant inebriating effects with rapid dissipation. In the event of repeated cycles of inhalation, a dangerous and uncontrolled systemic accumulation of trichloroethylene may occur, followed by central nervous system depression, coma and lethal cardiorespiratory arrest. Sometimes death occurs outside the hospital environment, without medical intervention or witnesses and without specific necroscopic signs. Medico legal investigations into sudden sniffing deaths associated with trichloroethylene demand careful analysis of the death scene and related circumstances, a detailed understanding of the deceased's medical history and background of substance abuse and an accurate evaluation of all autopsy and laboratory data, with close cooperation between the judiciary, coroners and toxicologists.

Generation Z: Adolescent Xenobiotic Abuse in the 21st Century.

NMDA receptor antagonists include the prescription medication ketamine, the illicit xenobiotics PCP, MXE, and other novel PCP analogs, and the OTC medication DXM. The NMDA receptor antagonist most commonly abused by adolescents in the United States is DXM. These xenobiotics cause dissociative effects by non-competitively inhibiting the action of glutamate at the NMDA receptor. Additionally, these agents modulate the actions of monoamine neurotransmitters, agonize opioid receptors, and inhibit nitric oxide synthase. Patients typically present with sympathomimetic and neuropsychiatric clinical manifestations after abuse of NMDA receptor antagonists. Treatment is generally symptomatic and supportive. Interventions include benzodiazepines, propofol, fluids, antiemetics, aggressive cooling, and respiratory support.

Does DSM-5 nomenclature for inhalant use disorder improve upon DSM-IV?

Among drug classes, substance use disorder (SUD) consequent to using inhalants (SUD-I) has perhaps the smallest evidence base. This study compared DSM-IV versus DSM-5 nomenclatures, testing whether 4 traditional categories of inhalants (aerosols, gases, nitrites, solvents) are manifestations of a single pathology, obtaining item parameters of SUD-I criteria, and presenting evidence that SUD can result from using nitrites. An urban, Midwestern, community sample of 162 inhalant users was recruited. Participants were 2/3 male, nearly 85% White, and had a mean age of 20.3 years (SD = 2.4 years), spanning the ages of greatest incidence of SUD and slightly older than the primary ages of inhalants use initiation. Analyses consisted of bivariate associations, principle components analysis, and item response theory analysis. Validity was demonstrated for SUD-I consequent to each inhalant type as well as for aggregating all inhalant types into a single drug class. Results supported DSM-5 nomenclature over DSM-IV in multiple ways except that occurrence of diagnostic orphans was not statistically smaller using DSM-5. (PsycINFO Database Record

Diagnostic performance of the atopy patch test with inhalant allergens

Background: This study evaluated the diagnostic performance of the atopy patch test (APT) compared with skin prick testing (SPT) and in vitro IgE measurement in a large group of patients with atopic dermatitis (AD) with or without respiratory symptoms (RS). Methods: The study included 521 patients (292 males, 229 females; age, 0.5-18 years; median age, 6 years) with AD and RS with different clinical presentations: current AD, 47 patients (Group A); current AD and RS, 72 patients (Group B), past AD and RS, 69 patients (Group C); and RS only, 280 patients (Group D). Fifty-three healthy individuals served as controls. All participants underwent the APT, SPT, and CAP/RAST with the most common inhalant allergens. The presence of a control group allowed calculation of specificity and positive and negative predictive values. Results: A significant difference was found for a positive APT versus both SPT and CAP/RAST (P<.0001) but not for SPT versus CAP/RAST. The differences for APT were significant in all group comparisons except group B vs C and group C vs D. In the control group, the APT was positive in 2% of cases (specificity of 96.2%), SPT was positive in 6% of cases (specificity of 88.4%), and CAP/RAST was positive in 4% of cases (specificity of 92.5%). Conclusions: In young patients sensitized to inhalant allergens with AD in addition to RS, the APT has a superior diagnostic performance to SPT and in vitro IgE measurement (AU)

Antecedentes: En este estudio se ha evaluado la capacidad diagnóstica de las pruebas epicutáneas con alérgenos inhalantes comparadas con las pruebas cutáneas en "prick" y con la determinación de IgE específica, en una población pediátrica numerosa de pacientes sensibilizados a inhalantes con dermatitis atópica con o sin síntomas respiratorios asociados. Métodos: En el estudio se incluyeron un total de 521 pacientes (292 varones, 229 mujeres, rango de edad 0,5 a 18 años, mediana 6 años) que presentaban los siguientes cuadros clínicos: dermatitis atópica activa, 47 pacientes (grupo A), dermatitis atópica y síntomas respiratorios activos, 72 pacientes (grupo B), antecedentes de dermatitis atópica y síntomas respiratorio no activos en la actualidad, 69 pacientes (grupo C) y solo síntomas respiratorios activos, 280 pacientes (grupo D); también se incluyeron como controles 53 sujetos sanos. A todos ellos se les realizaron pruebas epicutáneas con inhalantes, pruebas cutáneas en prick y determinación de IgE específica mediante técnica de CAST/RAST con una batería de inhalantes habituales de la zona. Se determinaron la especificidad y los valores predictivos positivos y negativos de la prueba. Resultados: Encontramos diferencia significativas en el rendimiento diagnóstico entre las pruebas epicutáneas con inhalantes tanto frente a las pruebas cutáneas en prick, como frente a la determinación de IgE específica (p< 0,001). No encontramos, por el contrario, diferencias entre las pruebas cutáneas en prick y la determinación de IgE específica. Cuando comparamos los grupos, en el caso de las pruebas epicutáneas con inhalantes todas las diferencias fueron significativas excepto las comparaciones entre el grupo B frente al grupo C y el grupo C frente al grupo D. Las pruebas epicutáneas con inhalantes fueron positivas en el 2% de los controles sanos, las pruebas cutáneas en prick en el 6% y la determinación de IgE específica en el 4%, lo que corresponde a una especificidad del 96,2% para las pruebas epicutáneas, del 88,4% para las pruebas en prick y del 92,5% para la determinación de IgE específica. Conclusiones: En pacientes pediátricos sensibilizados a inhalantes, no solo con dermatitis atópica sino también con síntomas respiratorios, las pruebas epicutáneas tienen una capacidad diagnóstica superior a las pruebas en prick o la determinación de IgE específica (AU)